Key Learning Points Research Articles

O03 Continuation of golimumab (anti-TNF) in a patient with SpA and low-risk prostate cancer, what is the right decision?

Case report - IntroductionGolimumab is an anti-TNF alpha drug used in the treatment of inflammatory arthritis including spondyloarthritis (SpA). The introduction of this drug class has revolutionised the treatment of SpA over the last 20 years with significantly improved patient outcomes.Despite their treatment benefits multiple adverse effects of TNF-alpha inhibition have been reported through clinical trials including a possible increased risk of malignancy.We describe a case of a patient with known ankylosing spondylitis (AS) on golimumab who was diagnosed with low-grade prostate carcinoma and discuss the factors taken into consideration in guiding our decision-making process regarding ongoing treatment. Case report - Case descriptionA 57-year-old gentleman with known AS presented to the rheumatology clinic for routine review. His AS was well controlled, and he had been taking golimumab for the past 3 years. Upon review he was in clinical remission with a CRP <1 and ESR 5. Prior to the initiation of anti-TNF therapy his disease had been poorly controlled. However, following commencement his symptoms had significantly improved and he was able to work as a professional sports coach whilst bringing up a young family.On review he had recently been diagnosed with low-risk cancer of the prostate by his urologist. A prostate biopsy found Gleason 3 + 3 adenocarcinoma involving 2 out of 22 cores on each side, with a prostate specific antigen (PSA) of 3.95ng/ml. An MRI had shown chronic prostatitis. He was in the lowest risk category of grade group 1 prostate cancer and no treatment for his prostate cancer was indicated. The plan from his urology team was active surveillance with PSA monitoring.Whilst being investigated for possible malignancy his golimumab had been held for six months and during this period he had a significant flare in symptoms. He experienced severe back pain that forced him to stop working. Following his prostate cancer diagnosis, golimumab was restarted by his urologist with a subsequent improvement in his AS symptoms.To guide ongoing treatment his case was reviewed in the local biologics multi-disciplinary team meeting, alongside close communication with his urologist. The patient was informed of the risks of continuing golimumab in relation to his malignancy. Despite this he was reluctant to stop anti-TNF therapy or switch to another treatment, citing concerns about the impact it might have on his symptoms and ability to work.Case report - Discussion This case highlights the complexities involved in the management of a patient on anti-TNF therapy, who receives a diagnosis of malignancy, particularly when the diagnosis is classed as low risk. Traditionally anti-TNF therapy was contraindicated for patients with a history of a solid organ tumour within the previous five years. The British Society of Rheumatology (BSR) guidelines recommends that patients should be advised that there is no conclusive evidence for an increased risk of solid organ tumours but that on-going vigilance is required.A holistic patient-centred approach needs to be taken in these contexts, and consideration of cases on an individual basis is needed. Inter-disciplinary and multi-speciality team input, with the effective use of a biologics MDT, is crucial. The patient was understandably reluctant to stop his treatment due to the significant impact this may have on his quality of life.On liaison with his urologist his prostate cancer was in the lowest risk category with 99% 5-year survival rates with low risk of disease progression or spread.Evidence in this field to date has been conflicting and studies have predominantly focused on the safety of anti-TNFs in rheumatoid arthritis patients. Recent large national registry data has been reassuring. Few studies have looked at the AS and psoriatic arthritis anti-TNF treated population; however, a meta-analysis of RCTs found no evidence of increased incidence of malignancy.Taking into account his low-risk cancer, the patient’s wishes and clinical evidence in this field we have made to decision to continue anti-TNF treatment for now but with ongoing surveillance for any tumour progression. The patient will undergo urology follow up alongside regular PSA monitoring, and there will be a low threshold to stop or switch treatment in the futureCase report - Key learning pointsTreatment with anti-TNF therapy in patients with concomitant inflammatory arthritis and malignancy pose a specific challenge that require close co-ordination of care between rheumatologists, oncologists, other relevant teams and may benefit from the use of local biologics MDT to guide ongoing drug therapy.It is important to take a patient centred approach and consider cases on an individual basis taking into account their cancer diagnosis, extent of disease, histology findings and their response to TNF treatment.Patients must always be counselled on the risk of continuing anti-TNF and be involved in the decision-making process.Further research is required to look at the safety of anti-TNF particularly in SpA and if there is an increased risk of malignancy.

O21 A case of thromboembolic ischaemic cardiomyopathy and intracardiac thrombus in a patient with antiphospholipid syndrome

Abstract Case report - Introduction Commonly found in association with lupus, antiphospholipid syndrome (APLS) is a potentially life-threatening disease of which an understanding is essential for rheumatologists. In addition to well-recognised sequelae such as pulmonary embolism and obstetric complications, APLS can provoke thrombi ranging from microscopic to massive in size in a wide range of arterial and venous territories. We present the case of a young woman with APLS who suffered significant morbidity as a result of intracardiac and coronary thromboembolism shortly after becoming pregnant and switching anticoagulant therapy, highlighting the importance of vigilance and investigation for rarer thromboses in APLS patients. Case report - Case description A 34-year-old woman with known APLS and 5 weeks pregnant was admitted to hospital with a history of headache, nausea/vomiting and mild photophobia followed by fever, shortness of breath, confusion, pleuritic chest pain and lower limb swelling. She had commenced enoxaparin in place of warfarin on becoming pregnant. Examination was suggestive of cardiac failure. Troponin and NTproBNP were markedly elevated, without ischaemic ECG changes. A brain CT venogram was reported as normal, but echocardiogram revealed a dilated LV with reduced ejection fraction (39%), inferior and lateral wall hypokinesia and possible LV thrombus. She was treated initially for myocarditis (presumed viral or autoimmune) and received antibiotics given her raised WCC and CRP. Treatment dose enoxaparin was continued. Bloods revealed anaemia, thrombocytopenia, and positive immunology: cardiolipin IgG 123U/ml, IgM 612, anti-B2GP1 IgG 19/IgM 607, ANA (1/320) and RNP 70. C3 was normal (0.8) and C4 low (0.03). A livedoid rash consistent with APLS was present on the trunk, but there were no other clinical manifestations of connective tissue disease. Repeat CT venogram performed after the patient reported worsening headaches revealed a small tentorial subdural haematoma, resulting in the reversal of enoxaparin with protamine. Later review of these images suggested a stable 5mm haematoma that was present on the earlier scan, and enoxaparin was recommenced. Cardiac MRI revealed extensive infarct with contained LV wall rupture. Coronary angiography showed normal vessels. LVEF on repeat echocardiogram fell to 28%. Surgical pregnancy termination was performed in accordance with patient wishes, with subsequent reversion to warfarin anticoagulation. Repeat MRI showed thinned anterior/lateral LV walls, evidence of transmural myocardial fibrosis and residual laminar thrombus, and bubble echo demonstrated no PFO. The patient was ultimately managed for presumed microembolic myocardial infarction with resulting heart failure, and has been referred to a cardiac transplant centre. Case report - Discussion This case highlights the potential risk associated with a relatively common scenario: anticoagulant switching in females with APLS at the start (or in anticipation) of pregnancy. In this case our patient started enoxaparin 80mg BD 48 hours after discontinuing warfarin, developing symptoms consistent with intracerebral thrombosis shortly afterwards, followed by those of heart failure. The possible diagnoses on the basis of the patient’s initial presentation were numerous, and she was appropriately investigated in the first instance for a possible cerebral thrombotic event with cranial CT and venogram. On development of cardiorespiratory symptoms, there was a delay in requesting investigations (troponin, BNP) that may have pointed towards myocardial pathology, and once these investigations were noted to be abnormal the patient was managed as a probable myocarditis in keeping with most other patients of her age without a significant past medical history. Perhaps insufficient diagnostic weight was given to her known thrombophilia and recent medication change, which may have prompted closer review of her brain imaging leading to earlier detection of the subdural haematoma. It may also have led to more rapid investigation for possible thrombus elsewhere via earlier echo, CTPA or cardiac MRI. The latter investigation was ultimately crucial in definitively showing myocardial injury to be the result of infarction rather than inflammation, where prior ECGs had not suggested ischaemia. The subsequent unremarkable coronary angiogram added weight to the likely thromboembolic nature of the infarction, potentially via multiple microemboli being thrown off the LV thrombus. The precise timing of the presumed embolisation to our patient’s coronary circulation is unclear, and the absence of overt ischaemic cardiac symptoms suggests this may have been a relatively prolonged, subacute process. Earlier recognition of the thrombotic nature of this event may have prevented myocardial injury if embolic showers continued into her inpatient stay. Case report - Key learning points

The Impact of COVID-19 and Lockdown on Spinal Services at a National Level: Lessons Learned and Areas of Service Improvement for Future Health Care Delivery.

The coronavirus disease 2019 (COVID-19) pandemic has had a dramatic impact on the provision of health care worldwide. The delivery of national spinal service for emergent surgery, elective surgery, and outpatient assessment has been incredibly challenging. A variety of innovative measures were undertaken to facilitate the safe provision of acute service and are outlined in this review, along with a number of key learning points which will improve the quality of health care delivered over the coming years. The challenges facing the spinal surgery community with regard the reintroduction of elective surgery is discussed, and a potential roadmap for the safe resumption of services is presented.

Dissection and Removal of Retroperitoneal Cyst of Unknown Origin

Study Objective The objective of this video is to highlight the application of basic surgical concepts for dissecting in the retroperitoneal space when challenged with unexpected findings. Design This is a video case report highlighting surgical concepts involving one patient. Setting The surgery was performed at a university hospital. Procedure was completed laparoscopically. Patients or Participants This video pertains to a 37-year-old who was incidentally found to have an adnexal mass while undergoing infertility evaluation. Patient demonstrates no evidence of recurrence to date. Interventions Patient underwent laparoscopic removal of retroperitoneal mass. Measurements and Main Results Once an adnexal mass was found on dedicated gynecologic ultrasound, patient was referred to gynecologic oncology for surgical intervention. Patient was taken to the operating room for right salpingo-oophorectomy. In the OR, patient was found to have normal ovaries and fallopian tubes bilaterally but a large retroperitoneal mass. Retroperitoneal space was accessed by opening up the pelvic sidewall. The cyst was found to be abutting the obturator nerve, which was identified early in the dissection process. Ureters, anterior division with its branches and external iliac vessels were all identified for anatomic orientation. Patient did well post-operatively. Final pathology demonstrated acellular fibrinous material origin not determined but no evidence of malignancy. Conclusion Key learning points from this case is that despite unexpected findings, surgical technique and application of core surgical principles can help navigate in a familiar space even when something unknown. Identifying key structures helps with orientation as well as avoidance of injury. Knowing the anatomy and utilizing techniques like traction and counter-traction, tissue planes could be better identified and dissected more easily. This case highlights whether working in a familiar or unfamiliar space, utilizing anatomical structures with core surgical principles can help guide dissection regardless of pathologic or anatomic distortions. The objective of this video is to highlight the application of basic surgical concepts for dissecting in the retroperitoneal space when challenged with unexpected findings. This is a video case report highlighting surgical concepts involving one patient. The surgery was performed at a university hospital. Procedure was completed laparoscopically. This video pertains to a 37-year-old who was incidentally found to have an adnexal mass while undergoing infertility evaluation. Patient demonstrates no evidence of recurrence to date. Patient underwent laparoscopic removal of retroperitoneal mass. Once an adnexal mass was found on dedicated gynecologic ultrasound, patient was referred to gynecologic oncology for surgical intervention. Patient was taken to the operating room for right salpingo-oophorectomy. In the OR, patient was found to have normal ovaries and fallopian tubes bilaterally but a large retroperitoneal mass. Retroperitoneal space was accessed by opening up the pelvic sidewall. The cyst was found to be abutting the obturator nerve, which was identified early in the dissection process. Ureters, anterior division with its branches and external iliac vessels were all identified for anatomic orientation. Patient did well post-operatively. Final pathology demonstrated acellular fibrinous material origin not determined but no evidence of malignancy. Key learning points from this case is that despite unexpected findings, surgical technique and application of core surgical principles can help navigate in a familiar space even when something unknown. Identifying key structures helps with orientation as well as avoidance of injury. Knowing the anatomy and utilizing techniques like traction and counter-traction, tissue planes could be better identified and dissected more easily. This case highlights whether working in a familiar or unfamiliar space, utilizing anatomical structures with core surgical principles can help guide dissection regardless of pathologic or anatomic distortions.

725 Experience of Implementing Diversity Teaching into University of Oxford

Abstract Background Medical education should equip students with the necessary skills to support the diverse population they treat and work with and be confident to act as an ally for patients and colleagues. We found there to be a gap for a diversity module in the curriculum at Oxford University. Method We created a diversity training session for over 300 medical students aiming to; The course consisted of a series of talks conducted by a senior lecturer on diversity, doctors, patients, and students, followed by small-group case-based teaching facilitated by a final-year medical student and a junior doctor. All facilitators underwent training by a senior lecturer on diversity. The cases encouraged students to reflect on their own personal biases and enact how they would confront discrimination on the wards. Students completed a survey before and after the session, rating self-confidence on six key learning points. Results 91.4% students agreed the session was useful to their medical training. There was a significant increase in students who felt confident implementing all learning points: defining key terms (post-session: 95.4%, pre-session: 82.3%); understanding health inequalities (post-session: 93%, pre-session: 54.6%); awareness of personal bias (post-session: 87.9%, pre-session: 70%); partaking in allyship (post-session: 95%, pre-session: 89.5%); and being an active bystander (post-session: 91.4%, pre-session: 45.9%). 79.3% felt confident to challenge acts of discrimination (33.6% pre-session). Conclusions This session educates and empowers students to challenge acts of discrimination. We recommend the implementation of similar sessions at all medical schools.

1505 EASiE: ENT and Airway Simulation in Emergencies

Abstract Aim A literature review of undergraduate ENT teaching found that most final year medical students and junior doctors did not feel adequately prepared for clinical practice in ENT. Other surveys found junior doctors lack confidence in recognising or initiating management in patients with blocked tracheostomies. To improve this, we ran a simulation session designed to replicate airway emergencies that junior doctors should be able to manage. The aim was to improve confidence in and knowledge of basic management of airway emergencies, including tracheostomies. Method Groups of 4-6 final year medical students participated in 3 scenarios: 2 tracheostomy-related and 1 partially compromised airway. The students had attended a session introducing tracheostomies and the algorithms produced by the National Tracheostomy Safety Project for tracheostomy emergencies. A semi-structured debrief followed each scenario, highlighting key learning points. The students completed a pre- and post-session questionnaire, rating confidence in several domains related to the scenarios. Results Of 24 participants, the percentage of students who felt confident or very confident in the following domains were compared pre- and post-simulation respectively: recognising a potential airway problem (0% vs 71%); identifying an altered airway (0% vs 75%); managing a potentially compromised surgical airway (4% vs 71%); initially managing a compromised airway (8% vs 67%); and identifying when to escalate with a potential airway problem (25% vs 96%). Conclusions Simulation is a valuable tool that can be used to improve both knowledge and confidence in managing potential airway problems in final year medical students. This supports findings from other studies.

1617 SOCS: Surgical On-Call Simulation

Abstract Introduction Simulation is a well-known method of effectively teaching Medical students. The majority of the simulation scenarios are related to Medicine. Surgical simulation is a gap within the curriculum, especially Surgical on-call simulations. To improve this, we ran simulation sessions designed to replicate a General Surgery themed on-call shift that junior doctors should be able to manage. We aimed to improve confidence in clinical prioritisation and confidence in being an on-call Junior doctor, managing the most common on-call surgical tasks. Method Groups of 3-4 final year Medical students participated in a 2 hour-long simulated “on-call” shift, throughout the hospital. There were 8 scenarios, which ranged from prescribing to acute clinical scenarios. Students were given bleeps and were called at set times. They had to receive/give handovers and prioritise tasks according to clinical importance. A debrief following the session focussed on prioritisation and highlighted key learning points. The students completed a pre- and post-session questionnaire as assessment. Results The percentage of students who felt confident or very confident in the following domains were compared pre- and post-simulation respectively: confidence in clinical prioritisation (17% vs 86%); confidence in prescribing medication (0% vs 14%); confidence in escalation to seniors (33% vs 71%). 87.5% of the participants felt the session was an effective way to learn how to prioritise clinical tasks, and 100% felt this an effective way to learn about common General Surgical queries whilst on-call. Conclusions This project demonstrates how simulation is effective in improving confidence in prioritisation and knowledge within clinical practice, especially surgery.

976 Traumatic Damage to The Liver Capsule: An Unusual Cause of Small Bowel Obstruction

Abstract A 57-year-old man presented to the emergency department with severe abdominal pain. Three months prior to presentation, he had sustained blunt trauma to his right side whilst cycling but had not sought medical attention. On admission, a CT scan showed small bowel obstruction and he underwent an emergency laparotomy. Intraoperatively, a subcapsular liver haematoma was identified, with incarcerated, necrotic small bowel within the liver capsule. The patient underwent deroofing of the haematoma with an omental patch and a small bowel resection with primary anastomosis. Small bowel obstruction is a common presentation in A&amp;E and is responsible for half of emergency laparotomies in the UK each year. Although hepatic haematomas are also a relatively common complication of blunt trauma to the abdomen, associated bowel herniation into the liver capsule is very unusual. We believe this is the first time such a case of small bowel obstruction has been reported in the literature and we discuss details of operative management and highlight key learning points.

Improving the time to ileostomy closure following an anterior resection for rectal cancer in the UK.

Delayed closure of ileostomy following an anterior resection for rectal cancer in the UK is common. The aims of this study were (i) to investigate the variation in patient pathways between hospitals, (ii) to identify the key learning points from units with the shortest time to closure and (iii) to develop guidance for a pathway to minimize delay in ileostomy closure. This was a mixed methods study. Thirty-eight colorectal units in the UK completed a short online survey. Nine colorectal units in Wales filled in an additional, expanded version of the survey. Semi-structured interviews were performed with clinicians from the six best performing units in terms of timely ileostomy closure. The optimal pathway suggested is based on the best evidence available and the Association of Coloproctology of Great Britain and Ireland guidelines. Qualitative analysis revealed that 5% of units (n=2) have a local target time for ileostomy closure. Of all units, 90% (n=34) would consider implementing a pathway if guidelines were developed. In-depth interviews highlighted the importance of a multidisciplinary approach, a dedicated coordinator to facilitate timely booking, and consensus on whether closure should be performed before or after adjuvant chemotherapy. There is a lack of national guidance in timing of contrast studies and ileostomy closure. Key aspects to consider are better information at consent regarding stoma closure timing, a dedicated person to track patients and the planning of contrast studies at discharge from initial surgery. With a dedicated approach closure of ileostomy within 10-12weeks is feasible for most units.

Stickler syndrome – lessons from a national cohort

In 2011 NHS England commissioned a new national specialist MDT service for patients and families affected by Stickler syndrome. The Stickler syndromes form part of the spectrum of inherited vitreoretinopathies and are the most common cause of retinal detachment in childhood and the most common cause of familial retinal detachment. Now in its 10th year, the Stickler Highly Specialised Service (HSS) has assessed 1673 patients from 785 families. Using a combination of accurate phenotyping and molecular genetic analysis it is possible to identify the underlying genetic mutation in over 95% of cases including those with deep intronic mutations likely to be missed by conventional exome panel analysis and which require whole gene sequencing and supplementary functional analysis to confirm pathogenicity. The vast majority that presents to ophthalmologists will be from one of three autosomal dominant sub-groups with a high associated risk of retinal detachment but the diagnosis is often overlooked, especially in adults. In contrast to many other blinding retinal conditions, blindness through giant retinal tear detachment particularly in children is largely preventable provided these high-risk groups are identified and appropriate evidence-based prophylaxis offered. This article summarises ten selected briefcase histories from the national dataset with key learning points from each.

64.1 TEACHING AND SUPERVISING CHILD AND ADOLESCENT FELLOWS ABOUT PERINATAL MENTAL HEALTH

The objective of this presentation is to fill the knowledge gap that exists in perinatal mental health training of both mental health clinicians and frontline health workers. Through the use of videos and lecture material, an attending will teach a child and adolescent psychiatry fellow how to teach healthcare workers caring for young new mothers and their children, so that both trainee and healthcare workers can gain further insight into how to best treat this unique population. A team of 1 attending psychiatrist (expert) and 1 child and adolescent psychiatry fellow (trainee) will demonstrate teaching frontline healthcare workers using a combination of lectures on perinatal mental health and videotaped dialogues discussing the content of the lectures. The dialogue will offer narratives that explore didactic content in the social and cultural context of the learners, using real-world scenarios commonly encountered in this population to underscore key learning points. The videos will focus on core clinical concepts related to perinatal mental health while also encouraging trainee and healthcare workers to recognize and explore underlying countertransferential reactions experienced through working with young mothers and their traumatized infants. Teaching perinatal mental health to trainees and healthcare workers fills an important knowledge gap in understanding and subsequently allows for more effective caregiving for young mothers and their infants. The use of lectures and videotapes of dialogues with common clinical scenarios presents a unique opportunity to improve the knowledge base in perinatal mental health of child and adolescent psychiatry trainees as well as healthcare workers.

Stakeholder experiences of using online spatial data visualisation tools for local public health decision support: A qualitative study.

The distribution of food outlets within towns and cities and the provision of active travel infrastructure have been associated with health behaviours that can contribute to obesity risk. Decision-makers describe a lack of local data and research evidence as a barrier to policy adoption to improve the public's health. Online spatial data visualisation tools created by researchers can help to bridge this gap. We explored stakeholder experiences of using such tools for decision-support, with a focus on facilitators and barriers to use. We conducted 16 qualitative interviews with Public Health, Planning and Transport Planning professionals, who had used two recently-developed tools. Participants described the importance of tools being open access; their use in “story-telling”, particularly to non-experts; and more broadly their use even when imperfect. They expressed that ‘robustness’ of underpinning data was important, however this was not easily defined. Participants employed personal heuristics, principally based on endorsement and developer credibility, to determine suitability for use. We present key learning points for future developers to maximise engagement and impact.

How to Look at the Covid-19 Pandemic Through Climate Governance?

Climate change has been the ‘wicked problem’ the world has struggled to address so far. Further, the Covid-19 pandemic has deeply affected the soft underbelly of global governance by redrawing boundaries and fissures in the existing system. The pandemic is possibly the single biggest event in the post-Second World War period or in the last seventy years to shape and affect human emotion, response and survival instincts. The world has seen catastrophic changes and huge loss of life. There are multiple parallels and differences between the two of the most significant challenges faced by the humanity. Even though climate scientists were harping on the catastrophic impact of climate change for the last four decades, at the broader human consciousness level, the severity of the problem has never sunk into the common psyche. Covid-19 is a vivid example as to how a pathogen-led pandemic can torment and pervade the all-powerful and the highest evolved species on the earth, that is, the mankind. In this backdrop, climate governance and an ideal-type governance typology is being looked at to provide some key insights and possible answers for the future. The concern has been looked through at two levels: personal at the behavioural level and collective at the global-scale levels. Future prescriptions rooted in the current realities have been explored to find a way out of the crisis and the key learning points from the pandemic to face the future with more confidence and certainty.

A contemporary approach to treat necrotic immature teeth using different bioceramic materials

Aim: The present report describes the endodontic treatment of an immature maxillary central incisor with an open apex and extensive periapical lesion. Summary: Cone-beam computed tomographic images demonstrated the unusual root canal anatomy and a contemporary approach using bioceramic intracanal dressing, root repair materials and root canal sealers were used. One year after the end of treatment, the patient was asymptomatic and a new cone-beam computed tomographic exam showed complete apical repair, with new bone formation and closure of the root apex. The combination of modern imaging and the use of contemporary materials contributed to adequate diagnosis, planning and treatment of this case. Key-learning points: Immature permanent teeth with apical periodontitis represent a clinical challenge. Calcium silicate-based materials are widely used in endodontics, mainly due to their excellent biological and physical properties. The association of different type of calcium silicate-based materials could be a good option of the treatment of immature permanent teeth with apical periodontitis.

Integrating variable risk preferences, trust, and transaction cost economics – 25 years on: reflections in memory of Oliver Williamson

AbstractIn this essay, we honour the memory of Oliver Williamson by reflecting on Chiles and McMackin's 1996Academy of Management Reviewarticle ‘Integrating variable risk preferences, trust, and transaction cost economics’. The article, which built on Williamson's work in transaction cost economics (TCE), went on to attract attention not only from the authors’ home discipline of management and organisation studies, but also from other business disciplines, the professions and the social sciences. After revisiting the article's origins and core arguments, we turn to selectively (re)view TCE's development since 1996 through the lens of this article, focusing on trust, risk and subjective costs. We cover conceptual and empirical developments in each of these areas and reflect on how our review contributes to previous debates concerning trade-offs implicit in relaxing TCE's behavioural assumptions. We conclude by reflecting on key points of learning from our review and possible implications for future research.

Reflections on the future visions of UK tourism outlined in Burkart and Medlik's 1974 book: tourism: past, present, and future

PurposeTo explore the future visions outlined in one of the first academic books on UK tourism to venture into tourism futures. Through today’s lens, their visions are explored through three topics: Future Markets and Destinations; Future Resources; and the Future Organization of Tourism.Design/methodology/approachExploring the backstory, key drivers and tipping points of UK tourism development and tourism education during the 1960s and 1970s, they help to understand the rationale for the authors 1974 future visions of UK tourism. These visions are tested against reality, using a mixture of data, softer evidence and the authors’ judgements.FindingsAcknowledging the authors showed courage in presenting their future visions, when so little was known about the development of tourism, let alone tourism futures. The article highlights the successes and failures of their future visions across 20 tourism sectors, through 55 tourism forecasts. The reasons for weaknesses in some of their forecasts, and their foresight in highlighting little known issues are explored, along with key learning points for tourism futurists.Research limitations/implicationsThe future visions of UK tourism were tested against data and other evidence, but this was not always possible. Therefore, the success or failures of some of the visions are based on the authors’ judgement.Originality/valueOver the past 50 years, there has been a steady growth in tourism futures studies. Given the recent increase in awareness of history in driving futures thinking, perhaps now is the time to apply this viewpoint to previously published tourism futures studies because such reviews provide a timely reminder of the transient nature of tourism futures gazing.

Patterns of immunotherapy-induced pneumonitis in patients with non-small-cell lung cancer: a case series

BackgroundImmunotherapy has become an efficacious option in the management of solid organ malignancies. Immune-related adverse events including pneumonitis are well described and may be particularly of concern in patients receiving immunotherapy for non-small-cell lung cancer.Case presentationsIn this paper, we describe three cases of immunotherapy-induced pneumonitis occurring in the management of lung malignancy. Our cases include a 54-year-old Caucasian woman with squamous cell lung cancer who was successfully rechallenged with immunotherapy after prior significant pneumonitis, a 65-year-old Caucasian man with metastatic squamous cell lung cancer who developed pneumonitis after multiple cycles of uneventful immunotherapy, and a 73-year-old Caucasian man with squamous cell lung cancer who developed early-onset pneumonitis with rebound on steroid taper.ConclusionsThis case series has provided further insight into the presentation and risk factors for pneumonitis in patients with non-small-cell lung cancer. Each of the cases of immunotherapy-induced pneumonitis illustrates the different potential patterns that may arise when immunotherapy-induced pneumonitis develops. This case series provides key learning points that may assist physicians managing non-small-cell lung cancer with immunotherapy.

The Impact of Intervention Dose Form on Oral Language Outcomes for Children With Developmental Language Disorder.

Purpose The aim of this study was to extract key learning from intervention studies in which qualitative aspects of dosage, dose form, have been examined for children with developmental language disorder (DLD)-in vocabulary, morphosyntax, and phonology domains. This research paper emerged from a pair of systematic reviews, aiming to synthesize available evidence regarding qualitative and quantitative aspects of dosage. While quantitative aspects had been experimentally manipulated, the available evidence for dose form (tasks or activities within which teaching episodes are delivered) was less definitive. Despite this, the review uncovered insights of value to DLD research. Method A preregistered systematic review (PROSPERO ID: CRD42017076663) adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was completed. Included papers were quasi-experimental, randomized controlled trial, or cohort analytic studies, published in any language between January 2006 and May 2019; oral language interventions with vocabulary, morphosyntax, or phonology outcomes; and participants with DLD (M = 3-18 years). The intention was to include papers in which dose form was experimentally manipulated or statistically analyzed, while quantitative dosage aspects were controlled, such that definitive conclusions about optimal dose form could be drawn and gaps in the evidence identified. Results Two hundred and twenty-four papers met the above inclusion criteria; 27 focused on dose form. No study controlled for all quantitative aspects of dosage such that we could effectively address our original research questions. Despite this, key points of learning emerged with implications for future research. Conclusions There is tentative evidence of advantages for explicit over implicit instruction and of the benefits of variability in input, elicited production, and gestural and other visual supports. With careful design of dose form, there is potential to design more efficient interventions. Speech-language pathology research would benefit from an agreed taxonomy of dose form components and standardized reporting of intervention studies, to enable cross-study comparisons and a systematic accrual of knowledge to identify optimal dose form for clinical application.

Interactive virtual cases for emergency medicine physicians during the COVID-19 pandemic.

Continuing professional development activities often involve interactive learning modalities, such as simulation. The COVID-19 pandemic limited many in-hospital activities, at a time when practicing high stress procedural scenarios and testing rapidly evolving processes was coveted. Thus, an interactive virtual case curriculum was conceptualized, piloted, and implemented to provide ongoing professional development for emergency medicine (EM) physicians. Each interactive virtual case consisted of: (1) an online scenario delivered in survey format with multiple pathways dependent on participant responses; (2) a facilitated 1-h online debrief 1 week later; and (3) a summary document detailing key learning points distributed to all EM physicians, regardless of participation. This reproducible interactive virtual learning model influenced EM physician practice and confidence, improved participation in continuing professional development activities, and identified departmental areas for improvement. Participants have expressed a desire for these interactive virtual cases to continue for beyond the COVID-19 pandemic.Supplementary InformationThe online version contains supplementary material available at 10.1007/s43678-021-00155-2.

Postgraduate ethics training programs: a systematic scoping review

BackgroundMolding competent clinicians capable of applying ethics principles in their practice is a challenging task, compounded by wide variations in the teaching and assessment of ethics in the postgraduate setting. Despite these differences, ethics training programs should recognise that the transition from medical students to healthcare professionals entails a longitudinal process where ethics knowledge, skills and identity continue to build and deepen over time with clinical exposure.A systematic scoping review is proposed to analyse current postgraduate medical ethics training and assessment programs in peer-reviewed literature to guide the development of a local physician training curriculum.MethodsWith a constructivist perspective and relativist lens, this systematic scoping review on postgraduate medical ethics training and assessment will adopt the Systematic Evidence Based Approach (SEBA) to create a transparent and reproducible review.ResultsThe first search involving the teaching of ethics yielded 7669 abstracts with 573 full text articles evaluated and 66 articles included. The second search involving the assessment of ethics identified 9919 abstracts with 333 full text articles reviewed and 29 articles included. The themes identified from the two searches were the goals and objectives, content, pedagogy, enabling and limiting factors of teaching ethics and assessment modalities used. Despite inherent disparities in ethics training programs, they provide a platform for learners to apply knowledge, translating it to skill and eventually becoming part of the identity of the learner. Illustrating the longitudinal nature of ethics training, the spiral curriculum seamlessly integrates and fortifies prevailing ethical knowledge acquired in medical school with the layering of new specialty, clinical and research specific content in professional practice. Various assessment methods are employed with special mention of portfolios as a longitudinal assessment modality that showcase the impact of ethics training on the development of professional identity formation (PIF).ConclusionsOur systematic scoping review has elicited key learning points in the teaching and assessment of ethics in the postgraduate setting. However, more research needs to be done on establishing Entrustable Professional Activities (EPA)s in ethics, with further exploration of the use of portfolios and key factors influencing its design, implementation and assessment of PIF and micro-credentialling in ethics practice.